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Publication date: 04/22/1994

Table of Contents

Article

Patrick W. O'Carroll, M.D., M.P.H.
Office of the Director
Office of Program Support

Lloyd B. Potter, Ph.D., M.P.H.
James A. Mercy, Ph.D.
National Center for Injury Prevention and Control

Summary

Incidence rates of suicide and attempted suicide among adolescents and
young adults aged 15-24 years continue to remain at high levels. In 1992, to
aid communities in developing new or augmenting existing suicide prevention
programs directed toward this age group, CDC's National Center for Injury
Prevention and Control published Youth Suicide Prevention Programs: A
Resource Guide. The Resource Guide describes the rationale and evidence for
the effectiveness of various suicide prevention strategies, and it identifies
model programs that incorporate these strategies. This summary of the
Resource Guide describes eight suicide prevention strategies and provides
general recommendations for the development, implementation, and evaluation
of suicide prevention programs targeted toward this age group.

INTRODUCTION

The continued high rates of suicide among adolescents (i.e., persons aged
15-19 years) and young adults (persons aged 20-24 years) (Table 1) have
heightened the need for allocation of prevention resources. To better focus
these resources, CDC's National Center for Injury Prevention and Control
recently published Youth Suicide Prevention Programs: A Resource Guide (1).
The guide describes the rationale and evidence for the effectiveness of
various suicide prevention strategies and identifies model programs that
incorporate these strategies. It is intended as an aid for communities
interested in developing or augmenting suicide prevention programs targeted
toward adolescents and young adults. This report summarizes the eight
prevention strategies described in the Resource Guide.

METHODOLOGY

Suicide prevention programs were identified by contacting suicide
prevention experts in the United States and Canada and asking them to name
and describe suicide prevention programs for adolescents and young adults
that, based on their experience and assessment, were likely to be effective
in preventing suicide. After compiling an initial list, program representatives were contacted and asked to describe the number of persons exposed to
the intervention, the number of years the program had been operating, the
nature and intensity of the intervention, and the availability of data to
facilitate evaluation. Program representatives were also asked to identify
other programs that they considered exemplary. Representatives from these
programs were contacted and asked to describe their programs. The list of
programs was further supplemented by contacting program representatives who
participated in the 1990 national meeting of the American Association of
Suicidology and by soliciting program contacts through Newslink, the
association's newsletter.

Suicide prevention programs on the list were then categorized according
to the nature of the prevention strategy using a framework of eight suicide
prevention strategies:

School gatekeeper training. This type of program is designed to help
school staff (e.g., teachers, counselors, and coaches) identify and refer
students at risk for suicide. These programs also teach staff how to
respond to suicide or other crises in the school.

Community gatekeeper training. These programs train community members
(e.g., clergy, police, merchants, and recreation staff) and clinical
health-care providers who see adolescent and young adult patients (e.g.,
physicians and nurses) to identify and refer persons in this age group
who are at risk for suicide.

General suicide education. Students learn about suicide, its warning
signs, and how to seek help for themselves or others. These programs
often incorporate a variety of activities that develop self-esteem and
social competency.

Screening programs. A questionnaire or other screening instrument is used
to identify high-risk adolescents and young adults and provide further
assessment and treatment. Repeated assessment can be used to measure
changes in attitudes or behaviors over time, to test the effectiveness of
a prevention strategy, and to detect potential suicidal behavior.

Peer support programs. These programs, which can be conducted in or
outside of school, are designed to foster peer relationships and
competency in social skills among high-risk adolescents and young adults.

Crisis centers and hotlines. Trained volunteers and paid staff provide
telephone counseling and other services for suicidal persons. Such
programs also may offer a "drop-in" crisis center and referral to mental
health services.

Restriction of access to lethal means. Activities are designed to
restrict access to handguns, drugs, and other common means of suicide.

Intervention after a suicide. These programs focus on friends and
relatives of persons who have committed suicide. They are partially
designed to help prevent or contain suicide clusters and to help
adolescents and young adults cope effectively with the feelings of loss
that follow the sudden death or suicide of a peer.
After categorizing suicide prevention efforts according to this
framework, an expert group at CDC reviewed the list to identify recurrent
themes across the different categories and to suggest directions for future
research and intervention.

FINDINGS

The following conclusions were derived from information published in the
Resource Guide:

Strategies in suicide prevention programs for adolescents and young
adults focus on two general themes. Although the eight strategies for
suicide prevention programs for adolescents and young adults differ, they
can be classified into two conceptual categories:

Strategies to identify and refer suicidal adolescents and young
adults for mental health care. This category includes active
strategies (e.g., general screening programs and targeted screening
in the event of a suicide) and passive strategies (e.g., training
school and community gatekeepers, providing general education about
suicide, and establishing crisis centers and hotlines). Some passive
strategies are designed to lower barriers to self-referral, and
others seek to increase referrals by persons who recognize suicidal
tendencies in someone they know.

Strategies to address known or suspected risk factors for suicide
among adolescents and young adults. These interventions include
promoting self-esteem and teaching stress management (e.g., general
suicide education and peer support programs); developing support
networks for high-risk adolescents and young adults (peer support
programs); and providing crisis counseling (crisis centers, hotlines,
and interventions to minimize contagion in the context of suicide
clusters). Although restricting access to the means of committing
suicide may be critically important in reducing risk, none of the
programs reviewed placed major emphasis on this strategy.

Suicide prevention efforts targeted for young adults are rare. With a few
important exceptions, most programs have been targeted toward adolescents
in high school, and these programs generally do not extend to include
young adults. Although the reasons for this phenomenon are not clear, the
focus of prevention efforts on adolescents may be because they are
relatively easy to access in comparison with young adults, who may be
working or in college. In addition, persons who design and implement such
efforts may not realize that the suicide rate for young adults is
substantially higher than the rate for adolescents (Table 1).

Links between suicide prevention programs and existing community mental
health resources are frequently inadequate. In many instances, suicide
prevention programs directed toward adolescents and young adults have not
established close working ties with traditional community mental health
resources. Inadequate communication with local mental health service
agencies obviously reduces the potential effectiveness of programs that
seek to identify and refer suicidal adolescents and young adults for
mental health care.

Some potentially successful strategies are applied infrequently, yet
other strategies are applied commonly. Despite evidence that restricting
access to lethal means of suicide (e.g., firearms and lethal dosages of
drugs) can help to prevent suicide among adolescents and young adults,
this strategy was not a major focus of any of the programs identified.
Other promising strategies, such as peer support programs for those who
have attempted suicide or others at high risk, are rarely incorporated
into current programs.
In contrast, school-based education on suicide is a common strategy. This
approach is relatively simple to implement, and it is a cost-effective
way to reach a large proportion of adolescents. However, evidence to
indicate the effectiveness of school-based suicide education is sparse.
Educational interventions often consist of a brief, one-time lecture on
the warning signs of suicide -- a method that is unlikely to have
substantial or sustained impact and that may not reach high-risk students
(e.g., those who have considered or attempted suicide). Further, students
who have attempted suicide previously may react more negatively to such
curricula than students who have not. The relative balance of the
positive and the potentially negative effects of these general
educational approaches is unclear.

Many programs with potential for reducing suicide among adolescents and
young adults are not considered or evaluated as suicide prevention
programs. Programs designed to improve other psychosocial problem areas
among adolescents and young adults (e.g., alcohol- and drug-abuse
treatment programs or programs that provide help and services to
runaways, pregnant teenagers, and/or high school dropouts) often address
risk factors for suicide. However, such programs are rarely considered
suicide prevention programs, and evaluations of such programs rarely
consider their effect on suicidal behavior. A review of the suicide
prevention programs discussed in the Resource Guide indicated that only
a small number maintained working relationships with these other
programs.

The effectiveness of suicide prevention programs has not been demonstrated. The lack of evaluation research is the single greatest obstacle
to improving current efforts to prevent suicide among adolescents and
young adults. Without evidence to support the potential of a program for
reducing suicidal behavior, recommending one approach over another for
any given population is difficult.

RECOMMENDATIONS

Because current scientific information about the efficacy of suicide
prevention strategies is insufficient, the Resource Guide does not recommend
one strategy over another. However, the following general recommendations
should be considered:

Ensure that suicide prevention programs are linked as closely as possible
with professional mental health resources in the community. Strategies
designed to increase referrals of at-risk adolescents and young adults
can be successful only to the extent that trained counselors are
available and mechanisms for linking at-risk persons with resources are
operational.

Avoid reliance on one prevention strategy. Most of the programs reviewed
already incorporate several of the eight strategies described. However,
as noted, certain strategies tend to predominate despite insufficient
evidence of their effectiveness. Given the limited knowledge regarding
the effectiveness of any one program, a multi-faceted approach to suicide
prevention is recommended.

Incorporate promising, but underused, strategies into current programs
where possible. Restricting access to lethal means of committing suicide
may be the most promising underused strategy. Parents should be taught to
recognize the warning signs for suicide and encouraged to restrict their
teenagers' access to lethal means. Peer support groups for adolescents
and young adults who have exhibited suicidal behaviors or who have
contemplated and/or attempted suicide also appear promising but should be
implemented carefully. Establishment of working relationships with other
prevention programs, such as alcohol- and drug-abuse treatment programs,
may enhance suicide prevention efforts. Furthermore, when school-based
education is used, program planners should consider broad curricula that
address suicide prevention in conjunction with other adolescent health
issues before considering curricula that address only suicide.

Expand suicide prevention efforts for young adults. The suicide rate for
persons in this age group is substantially higher than that for adolescents, yet programs targeted toward them are sparse. More prevention
efforts should be targeted toward young adults at high risk for suicide.

Incorporate evaluation efforts into suicide prevention programs.
Planning, process, and outcome evaluation are important components of any
public health effort. Efforts to conduct outcome evaluation are imperative given the lack of knowledge regarding the effectiveness of suicide
prevention programs. Outcome evaluation should include measures such as
incidence of suicidal behavior or measures closely associated with such
incidence (e.g., measures of suicidal ideation, clinical depression, and
alcohol abuse). Program directors should be aware that suicide prevention
efforts, like most health interventions, may have unforeseen negative
consequences. Evaluation measures should be designed to detect such
consequences.
For a copy of the full report, Youth Suicide Prevention Programs: A

Resource Guide, write to Lloyd Potter, Ph.D., M.P.H., at the Centers for
Disease Control and Prevention, National Center for Injury Prevention and
Control, 4770 Buford Highway, Mailstop K-60, Atlanta, GA 30341-3724. Single
copies are available free of charge.

References

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